Publications iconKansas Register

Volume 40 - Issue 20 - May 20, 2021

State of Kansas

Department for Aging and Disability Services

Request for Applications

The Department for Aging and Disability Services (KDADS), announces the release of a Request for Application (RFA) to qualified applicants to provide services to produce outcomes requested in the goal areas identified within the RFA. Applications will be accepted no later than 2:00 p.m. (CST) June 11, 2021. A complete copy of the RFA with details of important dates and timelines may be found at or on Page 2 of the RFA. Additional files may be located at this website throughout the process so please monitor on a regular basis for changes.

Kansas Prevention Collaborative-Community
Initiative (KPCCI) Substance Abuse Prevention
Implementation Grant-Cohort V(B)

Request for Application Timeline

Release of Request for Application May 17, 2021
Questions submitted by
Please include questions about the application if you have any
May 31, 2021
Response to Questions Posted June 3, 2021
Pre-Application Webinar
(785-414-8630, 187737044#)
June 4, 2021
Applications Due June 11, 2021
Awards Announced No later than June 25, 2021
Grant Phase July 1, 2021 – June 30, 2022

Submit application and questions to, Cc:,, and


The Kansas Department for Aging and Disability Services (KDADS), Behavioral Health Services Commission, announces the release of a Request for Applications (RFA) for Implementation grant (Cohort IV) that will allow eligible applicants to engage in a comprehensive community-based strategic plan that will result in community driven strategies to reduce underage drinking, youth marijuana use, health disparities shared risk and protective factors and produce sustainable systems change.

  • Behavioral health disparities pose a significant threat to the most vulnerable populations in our society. Whether manifesting themselves as elevated rates of substance misuse among American Indian/Alaska Natives, high rates of suicide among LGBTQ youth, or reduced access to prevention services among people living in rural areas, these disparities threaten the health and wellness of these populations and of our society as a whole. To overcome systemic barriers that may contribute to disparities, planners must be culturally competent. They must recognize and value cultural differences—such as those in the health beliefs, practices, and linguistic needs of diverse populations. They must develop and deliver prevention programs and practices in ways that ensure members of diverse cultural groups benefit from their efforts.

This Kansas Prevention Collaborative-Community Initiative (KPCCI) is intended to reduce underage drinking, youth marijuana use, shared risk and protective factors, produce sustainable systems change, and prevent substance abuse in identified communities and enrich prevention efforts across the state through the implementation and sustainability of evidence-based strategies, culturally competent prevention strategies. Grantees will be supported by each of the Kansas Prevention Collaborative partners. You can find out more about each of these partners at

With the use of Substance Abuse Block Grant funds, the Kansas Prevention Collaborative has a primary objective to help communities plan, implement, and evaluate activities that prevent and treat substance abuse. Integration of other identified priority behavioral health areas is encouraged when possible to supplement substance abuse prevention. These funds are intended for the focus of primary prevention efforts directed at individuals not identified to be in need of treatment services.

This initiative will utilize the five steps of the SAMHSA Strategic Prevention Framework (SPF) with focus on all steps of the SPF 1, 2, 3, 4, and 5. SPF is a community-based approach to substance abuse prevention that cuts across existing programs and systems. SPF executes a data-driven, five-step process known to promote youth development, reduce risk-taking behaviors, build assets and resilience, and prevent problem behaviors across the life span. The SPF was initiated by SAMHSA and the Center for Substance Abuse Prevention (CSAP). The five steps of the SPF are designed to help states and communities build prevention competencies and infrastructure necessary to implement and sustain effective prevention policies, practices, and programs. An outline of the five-step process of the Strategic Prevention Framework follows. A general overview of each step is presented below.

Visit to learn more about the Strategic Prevention Framework.

Step 1: Assessment

  • The purpose of this step is to understand local prevention needs based on a careful review of data gathered from a variety of sources. These data help planners to identify and prioritize the substance misuse problems present in their community; clarify the impact these problems have on community members; identify the specific factors that contribute to these problems; assess readiness; and determine the resources required to address those factors. Ultimately, a thorough and inclusive assessment process helps to ensure that substance misuse prevention efforts are appropriate and on target.

Step 2: Capacity Building

  • In this step, local resources are built and mobilized and the community’s readiness to address priority substance misuse problems is determined. In Step 1, planners took stock of what was available in their communities. In Step 2, they ensure the readiness of the community to buy in to the prevention effort and take stock of the resources needed to tackle the problem and produce a positive change. A community needs both human and structural resources to establish and maintain a prevention system that can respond effectively to local problems. It also needs people who have the motivation and willingness—that is, the readiness—to commit local resources to addressing these problems.

Step 3: Strategic Planning

  • Strategic planning increases the effectiveness of prevention efforts by ensuring that prevention planners select and implement the most appropriate programs and strategies for their communities. In an effective planning process, communities involve diverse stakeholders, replace guesswork and hunches with data driven decisions, and create comprehensive, evidence-based prevention plans to address their priority substance misuse problems.

Step 4: Implementation

  • In this step, a community’s prevention plan is put into action by delivering evidence-based programs and practices as intended. To accomplish this task, planners will need to balance fidelity and adaptation, and establish critical implementation supports.

Step 5: Evaluation

  • In the SPF, evaluation is about enhancing prevention practice. It is the systematic collection and analysis of information about prevention activities to reduce uncertainty, improve effectiveness, and facilitate decision-making.

The SPF is guided by two cross-cutting principles that should be integrated into each of the steps that comprise it:

  • Sustainability – the capacity of a community to produce and maintain positive prevention outcomes over time. To maintain positive outcomes, communities will want to sustain an effective strategic planning process as well as those programs and practices that produced positive prevention results. Accomplishing these dual tasks requires the participation, resolve, and dedication of diverse community members and a lot of careful planning.
  • Cultural competence – one of the SPF’s two guiding, cross-cutting principles and, as such, should be integrated into each step of the framework’s implementation. By considering culture at each step, planners can help to ensure that members of diverse population groups can actively participate in, feel comfortable with, and benefit from prevention practices.

I. Purpose

The KPCCI Implementation Grant is intended to reduce underage drinking, youth marijuana use, health disparities, shared risk and protective factors, produce sustainable systems change. Reduce and prevent substance abuse in identified communities and enrich prevention efforts across the state through the implementation and sustainability of evidence-based strategies, culturally competent prevention strategies. The grant is intended for primary prevention only.

Community coalitions that are awarded this grant will be better prepared to apply for, and secure, other state and national resources to support the implementation and evaluation of their comprehensive plans and efforts to continue work with their communities. KDADS and the Kansas Prevention Collaborative will provide communities with support to make the best use of their efforts throughout the implementation phase.

Utilizing funding and technical assistance, community coalitions will analyze local data that is contributing to substance abuse within their identified geographic area. Resources and technical assistance will be provided to review local assessment profile, logic model, and action plan to address these issues using the five-step SPF process (i.e., assessment, capacity building, planning, implementation, and evaluation). This will also include reviewing plans for sustainability, cultural competence, and evaluation.

II. Eligibility

Kansas Department for Aging and Disability Services invites applications from private, nonprofit and/or community organizations.

Eligible applicants and their fiscal agents must be existing community coalitions for at least the past six months and may include local government agencies, schools, public universities and colleges, private and/or or not-for-profit 501(c)(3) organizations based in the targeted community. Community coalitions shall be defined as a multiple sector partnership, mobilized at the local level to make their communities safer, healthier, and drug-free. Effective community coalitions must possess a stable and effective organizational structure with clearly defined roles, responsibilities, and may include multiple geographic areas or school district boundaries that are efficiently and effectively able to work together (e.g., a rural, multi-county partnership).

Existing Community Defined:

  • An established coalition that is already formed and can prove they have existed at least 6 months prior to the RFA release date. We asked that documentation be submitted to demonstrate that you are an existing coalition, providing minutes, names of members, meetings and general functionable activities in place or plans in place for other work, etc. (Only send a copy of minutes for one month prior to December 2020)
  • No group can be developed prior to the RFA by collaborating with others to meet the guidelines for the RFA, where no established work has not been done as a coalition earlier than 6 months.

III. Outcomes/Goal(s)

To reduce underage drinking, youth marijuana use, shared risk and protective factors, produce sustainable systems change, and prevent substance abuse in identified communities and enrich prevention efforts across the state through the implementation and sustainability of evidence-based strategies, culturally competent prevention strategies through the implementation and sustainability of effective, culturally competent and diverse prevention strategies. Implementation grantees will demonstrate progress made toward community assessment and readiness, building capacity, addressing cultural competency, by developing a solid coalition infrastructure to create a comprehensive strategic plan that will make positive change in their community. This will be done by utilizing the Strategic Prevention Framework model. Community Coalitions will be implementing strategies during this grant phase. Strategies to be funded by KPCCI funding that are currently in place will be reviewed by the KPC team.

IV. Terms of the Grant

The award is for a 12-month grant year. Grantees successfully completing the first grant year will be eligible to transition into implementation year 2 and will receive additional grant funds, (based on performance, budget and compliance). The awarded implementation grantees will enter a binding legal agreement between the Kansas Department for Aging and Disability Services and the awarded recipient. The agreement requires the awarded grantee to comply with specific grant criteria, which includes mandatory trainings, weekly reporting, quarterly reports, monthly fiscal reports, and data collection. Should a community coalition not meet these requirements, they will be placed on high-risk status which could delay expense reimbursement, and/or affect future funding opportunities provided by the Kansas Department for Aging and Disability Services.

KPCCI Implementation Grantees

Note: Additional coalition-specific training and technical assistance events, virtually or on site, may be scheduled in coordination with individual coalitions to select ideal dates, times, and locations.

Deliverables and Reporting

  • Community coalitions will be required to collect and report relevant National Outcome Measures (NOMs) which is data required for the State to report to the Federal Government.
    • NOMs-The Substance Abuse and Mental Health Services Administration (SAMHSA) has identified ten domains for National Outcome Measures (NOMs). The domains embody meaningful, real-life outcomes for people who are striving to attain and sustain recovery, build resilience, and work, learn, live, and participate fully in their communities. The NOMs matrix represents the beginning of a state-level reporting system that, in turn, will create an accurate and current national picture of substance-abuse and mental-health services.
  • To assist the State’s compliance with federal and community level evaluation requirements, grantees will participate in the Kansas Communities That Care (KCTC) Student Survey and achieve a 60% participation rate.
  • Community coalitions will be expected to assess school district(s) in the area to be served as to whether there is an agreed upon plan for administration of the KCTC Student Survey. If not, the Community coalition will work with the KPC to develop an Action Plan to increase participation.
  • Community coalitions will participate in evaluation, and sensemaking as directed, through documentation in the Community Check Box which will be submitted weekly on Fridays at the end of business or 5:00 p.m.
    • CCB documentation – The community check box is a tool for coalitions to document their activities they are doing in the community. Upon receiving ongoing training in the CCB where coalitions will learn how to document, it will be expected each week that coalitions are documenting their community activities-where this is reviewed by the KPC to ensure documentation is being entered in the CCB.
    • Identifying population with BH Disparities – Coalitions will use data to identify additional gaps of at least one ‘at risk’ population within their community and implement prevention strategies to reduce risk among the identified at risk population taking into account diversity and health disparities with the intended goal to take a deeper dive into identifying populations of other diversities and ethnic backgrounds.
  • Community coalitions will be required to submit quarterly reports and monthly budget reports as specified in the Notification of Award.
  • Designated coalition members must demonstrate an ability to participate in all required training and technical assistance provided by the Kansas Prevention Collaborative. Training may be offered virtually or face to face. Funds may be used to assist with travel to and from these events. (see section IV)

V. Overview of Grant Awards

Implementation grants will be $32,000 per community for one-year grantees. Number of awards will be based on funds available.

KPCCI Implementation Grantees Training Dates

General Overview of Trainings

Trainings are scheduled throughout the year facilitated by the KPC Team members assigned to the training event to help coalitions to accomplish their goals expected in their grant deliverables. The training is mandatory where we ask at least one person from the coalition to be present, but strongly suggest two members to be present if possible. Dates, times, and locations are subject to change due to many contributing factors such as weather, and other unforeseen circumstances. Coalitions will be notified in a timely manner of any changes.

  • Grantees will be expected to attend 4 days of SAPTS training
  • Dates will be provided after award announcement

Quarter time periods for trainings are the following:

1st Quarter 2021 July 1, 2021 through September 30, 2021
2nd Quarter 2021 October 1, 2021 through December 31, 2021
3rd Quarter 2022 January 1, 2022 through March 31, 2022
4th Quarter 2022 April 1, 2022 through June 30, 2022

KPCCI Implementation–Cohort V Grantees (Dates TBD)

Training Event Date Time Location
Substance Abuse Prevention Skills Training (Required for KPCCI Implementation Grantees) August 2021 8/20 – 8:30 a.m. – 4:00 p.m.
8/21 – 8:30 a.m. – 4:30 p.m.
8/22 – 8:30 a.m. – 4:00 p.m.
8/23 – 8:30 a.m. – 1:30 p.m.
Behavioral Health Disparities and Cultural Competence (All Grantees) 1st quarter 10:00 a.m.–4:00 p.m. TBD
Fidelity 1st quarter 10:00 a.m.11:30 a.m. TBD
Community Check Box Training TBD Grantees with individual times TBD
Sense-making Documentation Review Event TBD TBD TBD
Community Check Box Training 3rd quarter TBD TBD
Sustainability 3rd quarter Recording available online to listen at any time TBD
Tri-Ethnic Readiness Assessment Training Recording available online, due by Recording available online to listen at any time TBD
Community Check Box Training 4th quarter TBD TBD
Data and Evaluation Workshop (all grantees) 4th quarter 10:00 a.m.–4:00 p.m. TBD
Implementation Presentations 4th quarter TBD Lawrence and Wichita
Sense-making Documentation TBD TBD Online

Note: Additional coalition-specific training and technical assistance events, virtually or on site, may be scheduled in coordination with individual coalitions to select ideal dates, times, and locations.

Community Coalitions will be required to engage in a multidisciplinary partnership committed to collaboratively work through each of the five steps of the SPF process identified community. To ensure diverse representation within SPF community coalitions, KDADS has elected to align the SPF award process with the 12-key community sectors required through the national Drug-Free Communities Support Program. This approach ensures the involvement of representatives from key community organizations and institutions who provide varying perspectives and interests in substance abuse prevention and related consequences.

Alignment with federal grant program requirements prepare Kansas communities to obtain additional resources to support and sustain local efforts. The 12 sector representatives required as member participants in each community coalition funded through the KPC are provided in Figure 2.

Figure 2
12-Key Community Sectors as Identified in the Drug-Free Communities Support Program
  1. Youth (18 or younger)
  2. Parents
  3. Business
  4. Media
  5. School
  6. Youth-serving organizations
  7. Law-enforcement agencies
  8. Religious or Fraternal organizations
  9. Healthcare Professionals (i.e. doctors, nurses, substance abuse treatment providers
  10. State, Local, or Tribal Government entities
  11. Civic or volunteer groups
  12. Other organizations involved in reducing substance abuse

Community Plan

Each community will submit a comprehensive plan to address targeted substance use, shared risk and protective factors, diversity and health disparities which includes a broad array of prevention strategies directed at individuals not identified to be in need of treatment.

Each community’s plan will be required to contain at a minimum the following components: All of the components below are important, however as recipients move through phase 2 each step will be assessed, reviewed by your DCCCA specialist and supported by the KPC team ensuring each step is met with the goal to move to the next step before the implementation year 2 phase. The 8 components are in alignment of what you recipients are expected to fulfill in their deliverables:

  • Demographics
  • Staffing patterns/organizing structures
  • Logic model to address underage drinking and/or youth marijuana use, health disparities, low perceived risk of harm from substance use, and other prioritized risk/protective factors
  • Action plans for evidence-based strategies
  • Cultural competency assessment and integration into action plan
  • Evaluation plan
  • Capacity development plan
  • Sustainability plan

Upon successful completion of this Implementation Grant, grantees will then be eligible for a continuation award contingent upon budget, compliance and performance. Continued funding will allow communities to continue execute strategies identified in their plans and evaluate outcomes.

VI. Notification of Grant Awards

Awarded grantees will be notified via email no later than June 12, 2020. The Kansas Prevention Collaborative partners will work closely with each of the grantees to initiate the implementation process. Community mobilizers will be required to participate in the learning events (virtual and/or in-person as determined). In addition, technical assistance will be provided throughout the implementation process. Community plans and supporting documents will be expected to be completed and approved by the Kansas Prevention Collaborative.

Training/Technical Assistance Support

Each community coalition will receive substantial support from the Kansas Prevention Collaborative partners.

  • KDADS prevention team will provide support to the grantee regarding compliance and fiscal management.
  • Grantees will receive community support from DCCCA specialists who will provide guidance on training and technical assistance.
  • Grantees will receive support from Greenbush with data and evaluation tools.
  • Grantees will receive support and training from KU on the reporting and documenting community activities.
  • Grantees will receive support with communication through the KPC from WSU, that includes training events, workshops, media campaigns/promotions, etc.

The Kansas Prevention Collaborative partners will assist with tools and resources to ensure a successful outcome. Grantees will also have additional opportunities to attend training events to strengthen their coalition. While it is not required, it is encouraged to budget travel to PreventionWorKS meetings that are held quarterly. In addition, several online tools and resources are available to grantees as they progress.

Kansas Prevention Collaborative Resources

PreventionWorKS is a statewide Behavioral Health Prevention Coalition led by members of local community coalitions. One of the goals of PreventionWorKS is to connect coalitions across the state in a way that allows them to be resources and supports to one another. Participation in PreventionWorKS is strongly encouraged. This statewide coalition provides an opportunity for local coalitions to connect, share successes and lessons learned to strengthen statewide efforts. This coalition of coalitions is led by a steering committee comprised of community coalition members and other professionals. This peer led committee incorporates local level needs into the resources provided during these quarterly events.

Prevention TalKS is a monthly podcast that is offered and led by experts who address a variety of topics around Behavioral Health issues and other factors associated to prevention and promotion. These are not mandatory but strongly recommended to attend some throughout the year.

The annual Kansas Prevention Conference will be held on October 21-22, 2021, with the pre-conference being held on the 20th in Wichita, Kansas. Scholarships will be made possible to grantees who would like to attend the conference.

VII. Application Instructions

Submission Information

Those interested in applying shall submit any questions regarding the RFA prior to May 31, 2021, via email to

Applications and required documents shall be submitted via email by 5:00 p.m. (CST) June 11, 2021. The application must be arranged in the order indicated in the “Application Checklist.” Applications must include all the components described in this section. Failure to submit an application that contains all the specified information may negatively affect the review of the application.

Applicants are required to be registered with (System Award Management) and hold a DUNS number at time of submission. This is a unique nine-digit identification number provided by Dun & Bradstreet. It may be obtained at no cost at the following website: or by calling 866-705-5711. Verification of the DUNS number must be submitted as part of the funding proposal.

Application and Required Documentation

  • Completed Applicant Information - (Attachment A) This is a standard form used for submission of proposals and related information. The Application page must be signed by an official authorized to sign.
  • 501(c)(3) Verification as appropriate
  • Current list of board members (if applicable, some coalitions may not have board members)
  • Budget Worksheet - (Attachment B) outlining how funds will be allocated. (These are estimates and can be revised if awarded) The Budget Worksheet and justification should thoroughly and clearly describe every category of expenses listed.
  • Program Narrative - The program narrative must include the following sections:
    • Community Description (20 points)
    • Community Capacity for Collaboration and Planning (20 points)
    • Cultural Competency (20 points)
    • Organizational Description (20 points)
  • Tax Clearance Certificate
  • All applicants must submit a “Tax Clearance.” This is a comprehensive tax account review to determine and ensure that the account is compliant with all primary Kansas Tax Laws administered by the Kansas Department of Revenue, Director of Taxation. Information pertaining to a Tax Clearance is subject to change(s), which may arise as a result of a State Tax Audit, Federal Revenue Agent Report, or other lawful adjustment(s). This may take up to 24 hours to obtain. This is not the same as an entity being tax-exempt. Do Not Submit Your Tax-Exempt Certificate.
  • To obtain a Tax Clearance Certificate, you must:
    • Go to to request a Tax Clearance Certificate
    • Return to the website the following working day to see if KDOR will issue the certificate
    • If issued an official certificate, print it or save and attach it to your signed renewal document
    • If denied a certificate, contact the Kansas Department of Revenue, Director of Taxation about why a certificate wasn’t issued
    • It may take up to 24-hours to obtain the certificate/tax clearance and are only valid for 30 days
    • Please note this is not the same as tax-exempt status
  • Please include a copy of your current Logic Model and Action Plan(s)
    • For each strategy include the action plan(s)
    • Please use the templates provided for logic model and action plan(s).

Program Narrative (No template provided)


The narrative should describe the target community and the coalition’s capability to engage in comprehensive community-based strategic planning that will result in a plan to address substance use disorder as it relates to prevention efforts and identifying shared risk and protective factors, diversity and health disparities that will produce sustainable systems change. The following guidance outlines the elements the narrative requests.

Please use Times Roman, 12-point font (10-point font for charts and graphs) and standard 1-inch margins. Headings for each section (1-4) should be clearly labeled. Applicants should clearly and comprehensively respond to each bullet within each of the sections described below.

  1. Community Description
    • Describe and define the community/geographical area served by the coalition that will be targeted by the efforts of this award.
    • Describe the challenges that address underage alcohol, marijuana use and/or ATOD presents in your community.
    • List the coalition membership by sector in Figure 2.
  2. Community Capacity, Readiness, Mobilization, and Implementation Efforts
    • Coalitions identified staff is required to dedicate their time for the entire work and expected to fulfill the requirements of the RFA. It is important that those identified who will be contributing part time efforts to this project that they manage out time to complete the deliverables.
    • Describe the coalition’s capacity to engage in community organizing.
      • Describe the ability to build on partnerships during the planning process.
      • Who will participate in the implementation process, how or what role?
    • Discuss your community coalition’s experience utilizing data to inform the decision making;
      • Describe any community needs assessment that has been done.
      • Describe both the readiness and capacity of your coalition to begin the implementation phase.
    • Discuss what activities have been implemented to increase readiness and capacity, discuss how the capacity and readiness for implementation will be increased during the implementation phase.
    • Describe the community mobilization that was required for the coalition to apply for this funding opportunity.
    • Describe the coalition’s experience working with grants and strategic planning.
    • Discuss any anticipated challenges or barriers and describe how those may be addressed.
    • List any coalition needs for training or technical assistance.
  3. Cultural Competency and Sustainability
    • Briefly describe the community’s culture and its diversity.
    • Describe how your community coalition represents the cultural groups in your community and what changes are needed to ensure cultural competence and diverse engagement.
    • Describe what will be required to improve cultural competency during the Implementation phase.
    • Discuss how long your coalition has been involved in prevention and what other sources of funding your community provides to the coalition’s prevention efforts.
  4. Organizational Description
    • If the coalition is not the fiscal agency for this application, please identify the fiscal agent and their role in project.
    • Describe how the community coalition intends to structure its staffing and resources to ensure completion of all planning deliverables, including how the coalition plans to address any challenges, barriers, etc.
    • Describe experience and capability in ensuring compliance with grant requirements including fiscal and progress reporting.

VIII. Selection Process

Applications will be evaluated according to the demonstrable capacity of the community coalition to create and implement a plan that produces community change. The Community coalition must articulate its understanding of the challenges posed in addressing community-level factors including but not limited to risk and perception of harm risk of harm and health disparities related to substance use. Consideration will also be given to those who demonstrate the willingness to support this grant and all key stakeholders involved. The quality and strength of the application narrative will also be considered. Grant applications will be reviewed based upon the following criteria.

Applicant Information & Required Documentation (Attachment A)
  • 501(c)(3) Verification as appropriate
  • List of Board Members and a Board Member Conflict of Interest Statement if a 501(c)(3)

Budget Worksheet (Attachment B) 15

Narrative 80
Community Description 20
Community Capacity for Implementation 20
Cultural Competency 20
Organizational Description 20

Application Checklist

The following sections must be submitted in this order, in a combined PDF format (one complete document):

____ Applicant Information (Attachment A)
____ 501(c)(3) verification as appropriate (Applicant provides)
____ List of Board Members (Applicant provides) if applicable
____ Budget Justification Worksheet (Attachment B)
____ Project Narrative (Applicant provides)
____ Tax Clearance Certificate (Applicant provides)
____ Logic Model (Attachment C)
____ Action Plan(s) one for each strategy (Attachment D)

Kansas Department for Aging and Disability Services views KPCCI community grant applicants and grantees as learning partners; while specific guidance, consultation, and deliverables have been identified by federal and state partners, much will be learned as community leaders engage in building sustainable capacity within targeted populations to infuse a prevention mindset into multiple disciplines. This will have a direct impact on attitudes, beliefs, and actions related to substance abuse prevention specific to their community. The Kansas Prevention Collaborative is committed to working mutually with community coalitions to provide clarity through email, telephone or in person, as needed. As part of its commitment to lead and foster learning, KDADS will strive to create an environment in which the expertise of community stakeholders is honored and supported through competent supports both face-to-face and virtual settings.

Attachment A - Applicant Information

A. Applicant Agency
City, ST Zip:
Telephone: Email:
B. Type of Agency ☐ Public ☐ Private Non-Profit ☐ Private Profit
C. Official Authorized to Sign Application
City, ST Zip:
Telephone: Email:
D. Project Director
City, ST Zip:
Telephone: Email:
E. Fiscal Agent
City, ST Zip:
Telephone: Email:

Attachment B

Applicant Name:
Fiscal Agent Name:
Position Name Annual/Salary/Rate Level of Effort
(hours or %)

Component Rate Wage Cost

Purpose of Travel Location Item Rate/Cost

Justification: Describe the purpose of travel and how costs are determined.
Item Cost

Items Rate Cost

(Consultant) Name Service Rate Cost Other

Justification: Explain the need for each agreement and how they relate to the overall project
Item Rate Cost

Justification: Breakdown costs into cost/unit: i.e. cost/square foot. Explain the use of each item requested.
Total Request: $
Total Request: $
Justification: Provide rational and indicate percentage of total award being expended on indirect costs:
Category Request
A. Personnel
B. Fringe
C. Travel
D. Equipment
E. Supplies
F. Contractual
G. Other
H. Direct Request
I. Indirect Costs (10% max)
J. Match (10%)
Total Projected Costs

Attachment C

KPCCI Logic Model
County: Coalition Name: Date:

What? Column 1 Why? Column 2
Risk Factors
How? Column 3
To what end? Column 4
Long Term Goals
From the assessment, define your area of need related to block grant priority areas (underage drinking and/or youth marijuana use) From the box at the bottom of the logic model, check the priority risk factor(s) underlying use of this substance. Provide data to support each risk factor. Describe the evidence-based strategies that will target the priority risk factors in order to reduce use of this substance List the long-term goals for your community prevention efforts - the outcome of successful strategy implementation (Reduction in underage drinking and/or youth marijuana use)

What? Why?
Risk Factors
To what end?
Long Term Goals
From the assessment process, define any alcohol or marijuana co-occurring area of need (suicide or problem gambling prevention/mental health promotion) List the priority risk factors underlying the co-occurring are of need. Provide data to support each risk factor Describe the evidence-based strategies that will target the priority risk factors in order to reduce area of need List the long-term goals for your community prevention efforts - the outcome of successful strategy implementation

List other strategies currently being implemented in your community

Attachment D



Please complete one action plan for each strategy on your logic model and then upload it to you appropriate KPCCI Grantee Documents link.

Strategy Name:
Outcome statement (Goal) relating to Youth Substance Use:
Outcome statement (Objectives) relating to Targeted Risk Factor(s):
What is the measure(s) for the objective? Where will you get the data? When is data collected? Who will make sure this happens?

Please list your specific key action steps for this strategy.


Activity/Action Steps:
What steps need to take place in order to effectively implement the strategy?
Target Date Persons/Groups to be involved
(* responsible party)

Laura Howard

Doc. No. 049145